Healthcare Provider Details

I. General information

NPI: 1679079511
Provider Name (Legal Business Name): KAELEY THERESE WHITING ALLEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2018
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 GOLF COURSE RD
GRAND RAPIDS MN
55744-8648
US

IV. Provider business mailing address

1111 SW 22ND AVE
GRAND RAPIDS MN
55744-9760
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-3401
  • Fax:
Mailing address:
  • Phone: 218-290-9562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number66248
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: